Every finding on record at Altenheim

Based on observation, medical record review, witness statement review, policy review and interview, the facility failed to ensure Resident #120's right great toe ulcer/abrasion was timely identified, assessed, monitored and treated and failed to complete wound treatments as ordered for Resident #90. Actual harm occurred when Resident #120, who was assessed as severely cognitively impaired, totally dependent on staff for most activities of daily living (ADL's) and had a history of infection to the right great toe, was found to have a right great toe skin impairment beginning in 05/05/25, however there was no nurse assessment or monitoring or physician-ordered treatment of the right great toe skin impairment from 05/05/25 to 07/05/25. Subsequently, on 07/05/25, Resident #120 developed a fever and an oozing, reddened, edematous, and malodorous right great toe, was sent to the emergency room and was diagnosed with osteomyelitis and sepsis due to the wound resulting in a five-day hospital stay requiring intravenous antibiotics. This affected two (Residents #120 and #90) of three residents reviewed for wounds. The census was 120.Findings include:1.Review of the medical record for Resident #120 revealed an admission date of 12/17/22 with diagnoses which included functional quadriplegia, dementia, Alzheimer's disease with early onset, metabolic encephalopathy, cellulitis of right toe, and acute osteomyelitis of right ankle and foot. Review of the skin integrity care plan dated 06/07/23 revealed Resident #120 had alteration in skin integrity due to actual sacral/coccyx pressure ulcer wound, history of pressure ulcers, advanced Alzheimer's dementia with severe cognitive deficits, peripheral venous stasis, history of chronic edema, advanced age, fragile skin, cardiac disease, presence of suprapubic catheter, history of penile erosion, and incontinence, and right great toe blister. Interventions included: inspect skin during routine care as needed, skin assessments per protocol, and monitor of signs and symptoms of infection: fever, redness, odor, purulent drainage, change in drainage consistency and type, increase in size of wound, pain, edema, and notify physician of changes. Review of the podiatrist progress note dated 02/21/25 revealed Resident #120 had a partial thickness ulcer noted to the dorsal right hallux (great toe) with resolving cellulitis noted to digit. There was mild peri-wound erythema. Hyperkeratotic tissue noted to the margins of the wound. Mild drainage noted. Wound measured: approximately 1 centimeter. Plan: debridement ulcer right foot with application antibiotic ointment, resident to finish oral antibiotics and reassess in three weeks. Review of the Skin Audit Report for State tested Nurse Aides (STNA's) dated 04/14/25 revealed Resident #120 had skin integrity issues red area scabbed on toes. and all 10 toes were circled. A nurse signed the Skin Audit Report. Review of Minimum Data Set (MDS) 3.0 annual assessment dated [DATE] revealed Resident #120 was severely cognitively impaired, had fluctuating inattention, used a wheelchair for mobility, and was totally dependent on staff for bathing, upper and lower body dressing, putting and taking off footwear, personal hygiene, rolling left and right, toileting, and transferring from bed to chair. Review of the Skin Audit Report for STNA's for Resident #120 dated 05/05/25 revealed Resident #120 had a skin integrity issue on the R toe with a dressing that was not new. A nurse signed the Skin Audit Report. Review of the physician orders from May 2025 revealed Resident #120 was ordered weekly skin checks – complete PointClickCare (PCC) [electronic medical record] Skin and Wound - Total Body assessment every night shift every Wednesday for skin integrity; the order began on 11/20/24. In addition, Resident #120 was ordered Complete Foot Assessment weekly on skin check day every night shift every Thursday for skin integrity; the order began on 11/20/24. Review of the May 2025 Treatment Administration Record (TAR) revealed Resident #120 had a Total Body Skin assessment on 05/07/25, 05/14/25, 05/21/25, and 05/28/25. Resident #120 had a Complete Foot Assessment on 05/07/25, 05/21/25 and 05/28/25; there was no evidence Resident #120 had a Complete Foot Assessment on 05/14/25. Review of the wound care physician progress note dated 05/07/25 revealed there was no evidence Resident #120's right great toe was assessed. Review of the Skin Audit Report for STNA's for Resident #120 dated 05/12/25 revealed there was a circle around the right great toe describing a bandage on the toe. A nurse signed the Skin Audit Report. Review of the Skin Audit Report for STNA's dated 05/19/25 revealed Resident #120 had a skin integrity issue and there was a circle around the right great toe describing a bandage on the toe. A nurse signed the Skin Audit Report. Review of the Foot/Podiatric Assessment II dated 05/21/25 revealed Resident #120 had thickened toenails. There was no evidence of skin impairment on the right great toe. Review of the wound care physician progress note dated 05/21/25 revealed there was no evidence Resident #120's right great toe was assessed. Review of the PCC Skin and Wound – Total Body Skin assessment dated [DATE] revealed Resident #120 did not have any new wounds. Review of the Skin Audit Report for STNA's dated 05/26/25 revealed Resident #120 had a skin integrity issue and there was a circle around the right great toe describing a bandage on the toe. A medication aide signed the Skin Audit Report. Review of the wound care physician progress note dated 05/28/25 revealed there was no evidence Resident #120's right great toe was assessed. Review of the Skin Audit Report for STNA's for Resident #120 dated 05/30/25 revealed there was circle around the right great toe describing a bandage to the toe. A nurse signed the Skin Audit Report. Review of the June 2025 Treatment Administration Record (TAR) revealed Resident #120 had a Total Body Skin assessment on 06/04/25, 06/11/25, 06/18/25 and 06/25/25 and a Complete Foot Assessment on 06/04/25, 06/11/25, 06/18/25 and 06/25/25. Review of the Skin Audit Report for STNA's dated 06/02/25 revealed Resident #120 had a skin integrity issue on the right big toe that was not new. There was a circle around the right great toe. A nurse signed the Skin Audit Report. Review of the PCC Skin and Wound – Total Body Skin assessment dated [DATE] revealed Resident #120 did not have any new wounds. Review of the Foot/Podiatric Assessment II dated 06/04/25 revealed Resident #120 had thickened toenails. There was no evidence of skin impairment on the right great toe. Review of the wound care physician progress note dated 06/04/25 revealed there was no evidence Resident #120's right great toe was assessed. Review of the Skin Audit Report for STNA's dated 06/06/25 revealed Resident #120 had a skin integrity issue on the right big toe that was not new. There was a circle around the right great toe. Review of the Skin Audit Report for STNA's for Resident #120 dated 06/09/25 revealed Resident #120 had skin integrity issues with patches on indicted areas above not new. There was a circle around the right great toe. A nurse signed the Skin Audit Report. Review of the wound care physician progress note dated 06/09/25 revealed there was no evidence Resident #120's right great toe was assessed. Review of the PCC Skin and Wound – Total Body Skin assessment dated [DATE] revealed Resident #120 did not have any new wounds. Review of the Foot/Podiatric Assessment II dated 06/12/25 revealed there was no evidence Resident #120 had skin impairment on the right great toe. Review of the Skin Audit Report for STNA's for Resident #120 dated 06/13/25 revealed there was a circle around the right great toe. A nurse signed the Skin Audit Report. Review of the wound care physician progress note dated 06/16/25 revealed there was no evidence Resident #120's right great toe was assessed. Review of the PCC Skin and Wound – Total Body Skin assessment dated [DATE] revealed there was no evidence Resident #120 had a new wound. Review of the Skin Audit Report for STNA's dated 06/20/25 revealed Resident #120 had skin integrity issues and there was a circle around Resident #120's right toes describing a bandage on the toes. A nurse signed the Skin Audit Report. Review of the Skin Audit Report for STNA's for Resident #120 dated 06/23/25 revealed Resident #120 had no new [skin impairments]. A medication aide signed the Skin Audit Report. Review of the wound care physician progress note dated 06/23/25 revealed there was no evidence Resident #120's right great toe was assessed. Review of the Skin Audit Report for STNA's dated 06/30/25 revealed Resident #120 had skin integrity issues and there was a circle around the right great toe describing a bandage on the toe. A nurse signed the Skin Audit Report. Review of the wound care physician progress note dated 06/30/25 revealed there was no evidence Resident #120's right great toe was assessed. Review of the July 2025 Treatment Administration Record (TAR) revealed there was no evidence Resident #120 had a Total Body Skin assessment on 07/02/25, as ordered however Resident #120 had a Complete Foot Assessment on 07/02/25. Review of Resident #120's medical record revealed no evidence of the Complete Foot Assessment completed on 07/02/25. Review of the Skin Audit Report for STNA's for Resident #120 dated 07/04/25 revealed there was a circle around the right great toe describing a bandage on the toe. A nurse did not sign/acknowledge the Skin Audit Report. Review of the Change of Condition assessment dated [DATE] timed 3:02 P.M. authored by Licensed Practical Nurse (LPN) #520 revealed Resident #120 had abnormal vital signs and a skin issue: febrile with a 102.4 degree Fahrenheit (F) fever, right foot was warm, redness, edema and foul odor. Right foot had 2+ pitting edema. Resident noted to have a foam dressing to his right toe with no proper treatment documented in PCC. When this nurse took foam dressing off of right great toe/foot, foot appeared red, had 2+ pitting edema, warm to touch and had a foul odor. No drainage noted besides scant amount of dried blood to foam dressing. This nurse cleaned foot and left it open to air. Vital collected as resident also seemed drowsier than this baseline, but able to respond. Febrile with temperature noted to be 100.7 degrees F, all other vitals stable and no signs of sepsis noted. Tylenol administered as 1:38 P.M. and Physician #751 notified. This nurse checked temperature and vital signs again 30 minutes after Tylenol administration and fever increased to 102.4 degrees F, other vitals stable. Physician #751 gave new order to send to hospital, if Resident #120's wife wanted 911 then that was okay. Resident #120's wife present and decided on 911. Resident sent out 911 to hospital and left facility at 2:40 P.M. Resident #120's wife appreciative and left with emergency medical services. Review of the hospital physician admission/history and physical progress note dated 07/05/25 timed 5:46 P.M. revealed chief complaint: unable to obtain, per Resident #120's wife, she noted a spot on his toe and brought it to the attention of nursing staff at nursing home. History of present illness: 85-year-male old presenting to the emergency department due to right foot infection, has history of ESBL/VRE infections. Resident's wife reported that he has had a spot on his right great toe which had been managed with local wound care however the dressing had not been changed in several days. She asked for nursing home staff to open it today and then noticed it was foul-smelling. This prompted her evaluation in the emergency room. Presented with fever and found to have leukocytosis (an increase of white blood cells in the blood, especially during an infection) of 19,000 (normal between 4,000 to 11,000), hypokalemia 3.3 (normal 3.5 to 5.2), anemia of hemoglobin of 12 (normal 13.5 to 17.6) and 39 (normal <36%). C-Reactive Protein (CRP) elevated at 102.2 (normal <10.0). X-Ray of right foot showed lucency of the 2nd through 5th metatarsals concerning for osteomyelitis – question of subcutaneous gas of the hindfoot concern for infection. Twelve-lead EKG showed sinus rhythm with occasional premature ventricular contraction (PVCs) 67 beats per minute. Physical exam: there was an ulcer of the right great toe with redness erythema and edema, decreased pulsation over the dorsalis pedis (DP) pulse of the right lower extremity. Assessment/plan: osteomyelitis right foot 2nd to 5th metatarsals heads with suspicious for gas producing infection/necrotizing infection of the right lower extremity, acute metabolic encephalopathy, hypokalemia, leukocytosis, anemia. Admit, Vanc/Zosyn/Clinda (antibiotics), follow cultures, MRI right foot, arterial studies/ABI to eval PAD, vascular/podiatry/infectious disease consults, replace potassium, and Lovenox. Review of the change of condition note dated 07/05/25 timed 6:20 P.M. authored by LPN #520 revealed this nurse phoned Resident #120's wife for update on resident and wife stated resident was staying overnight in hospital and that he had osteomyelitis to his foot and was started on two antibiotics in hospital. Review of the hospital physician progress note dated 07/07/25 timed 1:34 P.M. revealed history of present illness: sepsis from foot wound and mental status change. Review of the undated witness statement authored by LPN #520 revealed, on Saturday 07/05/25, [Resident #120's wife name] brought to this nurse's attention that she had received a bill in the mail for podiatry. She asked if [Resident #120] was on the podiatrist list. This nurse educated wife that resident was taken off the podiatrist list per her request in the past. Wife asked about a foam dressing that was on resident's right great toe and why it was there. I stated that I was not aware of a foam dressing being placed on his right great toe and there was no treatment in place. Wife also concerned due to resident being drowsy but arousable. This nurse assess resident, noted to have 100.7 fever with all other vitals within normal limits, noted to be more drowsy that his baseline. Foot assessed and a foam dressing was on right great toe, removed by this nurse. No initials, date or name was on dressing and looked fairly new. Foot appeared red, had 2+ pitting edema, warm to touch, and foul odor. Foot also appeared dry and scabbed area noted to inner great toe. This nurse cleansed toe and left open to air while reporting to [Physician #751]. This nurse has not seen to recently to recall when foot initially appeared this way. No previous verbal reports by staff were given to this nurse. Resident sent to [hospital] via 911 at 2:40 P.M. with wife present. Review of the witness statement authored by Certified Nurse Aide (CNA) #677 dated 07/08/25 revealed, I have not seen [Resident #120's] toe uncovered. He has had a bandage on it. I marked the shower sheet when I gave him a shower. Review of the witness statement authored by CNA #663 dated 07/08/25 revealed, over the past week, I have observed [Resident #120] toe covered in a pink padded bandage. I have not seen it uncovered. Review of the witness statement authored by CNA #665 dated 06/08/25 revealed, I [CNA #665] did not notice his R toe due to it being covered. Review of the nurses note dated 07/10/25 revealed Resident #120 returned from hospital at 6:10 P.M., vitals take by this nurse. 151/64 blood pressure, 18 respirations rate, 98.5 tympanic temperature, 105 pulse and 93% room air.Resident had a skin tear on right hand, bruising to the left side of abdomen, black scab on left [incorrect] big toe, blister on left leg and peripherally inserted central catheter (PICC) line in left arm. Review of the wound physician note dated 07/14/25 revealed Resident #120 had a right great toe abrasion measuring 0.8 centimeters by 0.6 centimeters with a scab with the plan to continue intravenous antibiotics for right great toe osteomyelitis. Observation on 10/20/25 at 11:05 A.M. revealed Resident #120 was sitting in a wheeled shower chair being pushed from the shower room into his room by two nurse aides. Interview, during the observation, with Resident #120 with attempted however unsuccessful. Interview on 10/20/25 at 11:35 A.M. with LPN/Unit Manager #523 revealed night shift nurses were supposed to complete resident's head-to-toe skin checks once a week. LPN #523 revealed she was unaware Resident #120 had a wound on the right great toe. LPN #523 verified Resident #120 did not have treatment order for the right great toe and verified she had no knowledge there was a dressing in place to the right great toe. Observation on 10/20/25 at 9:47 A.M. at Unit Three nursing station revealed there was a undated schedule hanging on the wall at the nursing station. The sign read, Unit 3: head to toe and foot assessment schedule. Tuesday: [Resident #120's room number]. These assessments must be completed under the assessment tab prior to you signing them in the TAR [treatment administration record]. There are two assessments to be completed per room. Observation on 10/20/25 at 1:20 P.M. revealed Resident #120 was sitting in a wheelchair in his room with his wife standing by his side. Interview, during the observation, with Resident #120 was attempted however unsuccessful. Interview on 10/20/25 at 1:20 P.M. with Resident #120's wife revealed she visited with Resident #120 for eight hours a day, every day so when she came in to visit on 07/05/25, the wife noticed the resident wasn't feeling good; he was sleeping a lot and kind of out of it. Resident #120's wife asked LPN #520 to check him and take his vital signs. LPN #520 found the resident to have a slight temperature and gave him Tylenol, however his temperature then increased. LPN #520 stated that the resident had an infection however she didn't know where. That was when Resident #120's wife asked, when is the bandage coming off his toe? Because it's been on there awhile. Resident #120's wife described the bandage as a big bandage with tape and covered the whole toe and the bandage wasn't dated or initialed. LPN #520 checked the computer and stated there wasn't anything in the computer about the toe. LPN #520 then removed the bandage from the right great toe which the toe was oozing pus (unknown color), swollen and malodorous. Resident #120's wife described it as awful and so bad. Resident #120 was sent to the hospital and diagnosed with osteomyelitis and was on all these antibiotics. The hospital told Resident #120's family he may lose part of his foot or whole foot. Resident #120's wife discussed the right great toe wound with the Director of Nursing (DON) and Administrator who reported no one knew about the wound and they didn't find out what happened. Physician #751 reported to Resident #120's wife that [the wound] wasn't in the computer. Interview on 10/20/25 at 1:35 P.M. with Physician #751 (Resident #120's primary care physician) revealed Physician #751 was unaware Resident #120 had a wound on the right great toe prior to 07/05/25. Physician #751 was sent a picture via text message of the resident's toe on 07/05/25 which showed the great toe was edematous, clearly infected and Physician #751 knew the resident was going to need IV antibiotics, a podiatrist consultation and imaging; it looked bad. Physician #751 stated there was a Band-Aid or a dressing of some sort covering his toe however the physician did not observe the dressing, only the foot. Physician #751 verified she was aware there was no documentation in the medical record for the right great toe. Interview on 10/20/25 with the DON (with the Administrator present) verified the following: Resident #120's shower sheets of a right great toe skin impairment began on 05/05/25, Resident #120's last Foot/Podiatric assessment under the assessment tab in the electronic medical record (EMR) was on 06/12/25, Resident #120's last Total Body Skin assessment under the assessment tab in the EMR was on 06/19/25, there was no corresponding Total Body Skin assessment under the assessment tab in the EMR from the weekly skin check on 06/19/25, there was no evidence a Total Body Skin assessment/weekly skin check was completed on 07/02/25, there was no physician ordered treatment for Resident #120's right great toe prior to 07/05/25, and Resident #120's right great toe was not being assessed and monitored by nursing. Interview on 10/21/25 at 9:15 A.M. with Resident #120's son revealed he had requested Resident #120's medical records from the facility. The son reviewed the facility's progress notes, Medication Administration Record (MAR's) and TAR's and noticed Resident #120 had a wound on his toe since May 2025 and there wasn't a treatment order for the toe. When Resident #120 was sent to the hospital during early July 2025, the hospital physician told Resident #120's family the resident might lose his toe or half his foot. Resident #120's son stated he was concerned that his father was going to die from an infection at the facility rather than old age. Observation on 10/21/25 at 9:23 A.M. revealed Resident #120's great toe treatment had was in place and dated 10/20/25. The right great toe noted to bend straight down at the knuckle (metatarsophalangeal joint). At the joint, there was a circular area that was being treated. Interview, during the observation, with Wound Nurse (WN) #563 revealed his toes had fractures from when he was younger due to playing football. He had great toenails removed prior to being admitted to the facility due to recurrent ingrown toenails. WN #563 stated she spoke to the resident's wife about getting him set up with a podiatrist regularly and wife stated she would. WN #563 stated during the time of April 2025 through 07/05/25, WN #563 had not noticed the right great toe having a bandage or a skin area. WN #563 did weekly rounds with the wound physician/wound nurse practitioner. WN #563 stated staff were supposed to update her with new skin areas. WN #563 was not updated until the day he went to the hospital. Interview on 10/21/25 at 2:15 P.M. with LPN #520 revealed on 07/05/25, Resident #120's wife notified LPN #520 that Resident #120 had a foam dressing on his right great toe and inquired when the last time the dressing was changed. The nurse was unaware of the foam dressing and when LPN #520 removed the foam dressing, the resident's right great toe was inflamed, red and had foul odor coming from the dressing. LPN #520 stated the dressing was not labeled, dated or initialed. LPN #520 report the findings to the physician, and the resident was sent to the hospital. LPN #520 revealed she hadn't seen a bandage on the right toe before 07/05/25. Interview on 10/21/25 at 3:30 P.M. with WN #563 (with the Administrator present) verified Resident #120 had a Foot/Podiatric assessment completed on 07/02/25 according to the July 2025 TAR however there was not a corresponding Foot/Podiatric assessment completed on 07/02/25 under the assessments tab in the EMR. Review of the facility undated Recognition and Assessment policy revealed direct care staff such as the assigned nursing assistant would be responsible to examine the resident's skin integrity during each care contact, i.e. during dressing, bathing, toileting, incontinence care, repositioning, etc. The nursing assistant would be responsible and expected to immediately report to their charge nurse any identified problems such as any redness, callus formation, abrasion, ecchymosis areas or other break in skin integrity. On resident shower days, the STNA would complete a Resident Shower Sheet and forward to the charge nurse for review. The charge nurse or treatment nurse complete a weekly head to toe assessment, as appropriate, on the resident and documents in the resident medical record. The charge nurse would be responsible for informing the resident's provider when any area of concern were identified so that appropriate measures could be taken to alter the plan of care and/or implement a treatment protocol if necessary. Existing wound were assessed by the wound nurse and wound provider on a weekly basis as appropriate for new areas, stagnant or declining wounds for effectiveness of current interventions and/or treatment. Weekly assessment findings would be recorded and entered in PCC. Review of the facility's undated Treatment and Interventions policy revealed unless otherwise specified by the provider, the facility's treatment protocols for each skin integrity type would be in accordance with current standards of practice. Generally, dressing would not be removed until the ordered dressing was due to be changed unless there were signs of dressing contamination or observations that indicate a clinical problem. Integrity of wound dressings would be monitored with each interaction and be replaced in they were not intact/placed as ordered. 2. Review of the medical record for Resident #90 revealed an admission date of 07/08/24 with diagnoses including dementia, chronic kidney disease and a pressure ulcer to the left heel and right heels. Review of the physician's orders for Resident #90 revealed an order to cleanse the left heel wound with normal saline, pat dry, swab with Betadine, cover with an abdominal (ABD) pad and wrap with kerlix every day and as needed dated 07/17/25. Review of the care plan dated 07/19/25 for Resident #90 revealed she was at risk for impaired skin integrity and had an unstageable pressure ulcer (type of pressure ulcer when the stage is not clear due to the base of the wound being obscured by dead tissue in the wound) to her left heel. Interventions included to perform treatments as ordered by the physician. Review of the treatment administration record (TAR) for Resident #90 for September 2025 and October 2025 revealed nursing staff had not completed the treatment to her left heel wound on 09/06/25, 09/10/25, 09/12/25, 09/15/25, 09/26/25, 09/29/25, 10/04/25, 10/05/25, 10/10/25, 10/13/25, 10/18/25 and 10/19/25. Interview on 10/21/25 at 1:32 P.M. with the Director of Nursing verified Resident #90's treatments to her left heel were not performed on the dates listed above. Review of the facility policy titled, Treatment and Interventions, undated, revealed unless specified by the provider, the facility's treatment protocols for each skin injury type will be in accordance with current standards of practice. This deficiency represents non-compliance investigated under Complaint Number 2601761.

Based on record review, observation and interview, the facility failed to implement proper infection control policies and procedures including surveillance of facility infections and contact isolation precautions (wearing gown and gloves) when in Resident #60's room. This affected one (Resident #60) of three residents reviewed for isolation precautions but had the potential to affect all residents related to not performing proper infection control surveillance. The facility census was 120.Findings include:1. Review of the monthly infection control surveillance logs from September 2024 through October 2025 revealed the facility did not have surveillance for the months of August 2025, September 2025 and October 2025. Interview on 10/21/25 at 12:00 P.M. with the Assistant Director of Nursing (ADON) #750 verified she had not started working on August 2025, September 2025 and October 2025 infection control surveillance logs. She stated she tracked infections but was unable to answer how she monitored for trending infections when the logs were not being kept up to date. Additional interview on 10/21/25 at 12:50 P.M. revealed ADON #750 ran a report at the end of each month for orders of new antibiotics and she utilized the information for her infection control surveillance log. Review of the facility policy titled, Antibiotic Stewardship Program, dated 05/15/24, revealed the infection prevention and control nurse would track and monitor facility infections and the amount of antibiotics used in the facility.2. Review of the medical record for Resident #60 revealed an admission date of 11/14/21 with diagnoses including chronic kidney disease, heart failure, diabetes mellitus, dementia and Extended Spectrum Beta Lactamase (ESBL) resistance (bacteria that is resistant to common antibiotics).Review of the physician's orders for Resident #60 revealed she had a peripherally inserted central catheter (PICC) dated 10/10/25. Resident #60 had an order dated 10/10/25 for contact precautions for ESBL.Observation on 10/20/25 at 10:45 A.M. revealed a sign on Resident #60's door alerting staff and visitors that she was on contact isolation. The instructions stated everyone must clean hands when entering room and wash hands with soap and water when leaving the room and put on a gown and gloves at the door. There was personal protective equipment (PPE) noted sitting by Resident #60's door including gloves and gowns. Licensed Practical Nurse (LPN) #536 performed hand hygiene and put on gloves. She then went into Resident #60's room and performed care on her PICC line. LPN #536 did not have a gown on during the observation. LPN #536 verified she should have donned a gown prior to going into Resident #60's room. Review of the facility policy titled, Infection Control, dated January 2012, revealed contact precautions were needed for multi-drug resistant organisms. Contact isolation included utilizing gown and gloves.This deficiency represents non-compliance investigated under Complaint Number 2601761.

Based on record review and interview, the facility failed to implement their antibiotic stewardship program to ensure appropriate use of antibiotics. This affected one (Resident #120) of three residents reviewed for antibiotic usage. The facility census was 120.Findings include:Review of the medical record for Resident #120 revealed an admission date of 12/17/22 with diagnoses including dementia, pressure ulcers, history of urinary tract infections and cellulitis of the right great toe, Review of the facility infection control surveillance for September 2024 through July 2025 revealed Resident #120 had been on antibiotics on 10/15/24 (for urinary tract infection), 11/01/25 (for urinary tract infection), 11/20/25 (for clostridium difficile, or infection of the colon that causes diarrhea), 02/18/25 (for cellulitis of the toe), 03/06/25 (for infection to the right toe), 03/31/25 (for increased white blood count), 04/03/25 (for continued increased white blood count), 06/09/25 (for conjunctivitis, or infection of the eye), and 07/10/25 (for osteomyelitis, or infection of the bone).Review of Resident #120's assessments revealed he did not have antibiotic time out assessments (standardized tool and criteria that assesses the symptoms of the resident and usage of the antibiotic) performed on 11/20/24, 02/18/25, 03/31/25-04/03/25, and 06/19/25.Interview on 10/21/25 12:50 P.M. with the Assistant Director of Nursing (ADON) #750 verified staff had not performed the antibiotic time out assessments for Resident #120 on 11/20/24, 02/18/25, 03/31/25-04/03/25, and 06/19/25. She stated the facility utilized the antibiotic time out assessments to ensure residents' symptoms warranted antibiotic usage and was part of their antibiotic stewardship program.Review of the facility policy titled, Antibiotic Stewardship Program, dated 05/15/24, revealed the infection prevention and control nurse would track all antibiotic starts as infection surveillance and monitor adherence to criteria during the evaluation and management of treated infections.This deficiency represents non-compliance investigated under Complaint Number 2601761.

Based on record review and interview, the facility failed to ensure staff performed urinary catheter care and monitored urine output as ordered by the physician. This affected two (Residents #79 and #120) of three residents reviewed for urinary catheters. The facility census was 120.Findings include:1. Review of the medical record for Resident #79 revealed an admission date of 09/30/25 with diagnoses including urinary retention, obstructive and reflux uropathy (blockage in the urinary tract that prevents urine from flowing normally). Review of the physician's orders for Resident #79 revealed an order for foley catheter care each shift dated 09/30/25. Review of the baseline care plan dated 09/30/25 for Resident #79 revealed she had a foley catheter and staff would provide catheter care as ordered. Review of the treatment administration record (TAR) for October 2025 revealed staff had not completed foley catheter care including monitoring urinary output on night shift on 10/03/25, 10/09/25, 10/10/25 and on dayshift on 10/10/25 and 10/17/25. Interview on 10/21/25 at 1:32 P.M. with the Director of Nursing verified Resident #79's foley catheter care was not performed on the dates listed above. Review of the facility policy titled, Urinary Catheter Care, dated April 2013, revealed care should be provided every shift and as needed. 2. Review of the medical record for Resident #120 revealed an admission date of 12/17/22 with diagnoses including dementia and obstructive and reflux uropathy (blockage in the urinary tract that prevents urine from flowing normally). Review of the care plan dated 06/07/23 for Resident #120 revealed he had alteration in elimination related to having a catheter. Interventions included for staff to perform suprapubic catheter care as ordered and monitor output as needed. Review of the physician's orders for Resident #120 revealed an order for suprapubic catheter (a catheter inserted directly into the bladder) care each shift dated 02/05/25 that was discontinued on 07/07/25. A new order on 07/22/25 was noted to monitor foley output every shift. Review of the treatment administration record (TAR) for May 2025, June 2025 and July 2025 revealed staff had not completed suprapubic catheter care for Resident #120 on dayshift on 05/01/25, 06/09/25 and on nightshift on 05/02/25, 05/08/25, 05/09/25, 05/14/25, 05/22/25, 05/27/25, 05/28/25, 06/02/25, 06/11/25, 06/24/25, 06/27/25, 06/30/25 and 07/02/25. Review of the TAR for July 2025, August 2025 and September 2025 also revealed Resident #120 did not have his foley output monitored on nightshift on 07/22/25, 07/23/25, 07/31/25, 08/03/25, 08/06/25, 08/07/25, 08/19/25, 08/20/25, 08/26/25, 08/28/25, 08/29/25, 09/05/25, 09/08/25, 09/16/25, 09/17/25, 09/19/25, 09/22/25, 09/25/25, 09/26/25 and on dayshift on 07/25/25 and 08/16/25. Interview on 10/21/25 at 1:32 P.M. with the Director of Nursing verified Resident #120's suprapubic catheter care and output was not monitored on the dates listed above. Review of the facility policy titled, Urinary Catheter Care, dated April 2013, revealed care should be provided every shift and as needed. This deficiency represents non-compliance investigated under Complaint Number 2601761.

Based on observation, interview, and facility policy review, the facility failed to ensure appropriate food storage in the kitchen's main freezer and the memory care unit refrigerators. The kitchen area had the potential to affect all residents receiving meals from the kitchen. The facility identified three residents (#36, #78, and #96) who had nothing by mouth (NPO) diet orders. The facility identified 24 residents (#16, #18, #19, #21, #24, #31, #37, #39, #50, #52, #55, #56, #59, #60, #66, #67, #69, #71, #72, #80, #83, #87, #90, and #95) on the memory care unit. The facility census was 115. Findings include: Observation on 07/22/24 from 8:15 A.M. to 8:30 A.M. with Assistant Director of Dietary Services #857 revealed the main freezer had an internal thermometer reading negative 19 degrees Fahrenheit. Inside the main freezer was significant amounts of frozen water drips across the ceiling of the freezer. There were ice crystals formed on boxes of stored food products along the top racks of the freezer. There was ice buildup noted on the two condensers. Assistant Director of Dietary Services #857 indicated she had previously put in a work order with maintenance; however, the freezer had not yet been inspected. There was a box of pretzel rolls spilled onto the floor of the freezer. All kitchen findings were verified at time of observation with Assistant Director of Dietary Services #857. Observation on 07/22/24 at 8:42 AM with Assistant Director of Dietary Services #857 on the secure memory care unit revealed a mini refrigerator freezer located in the nursing station. There was noted ice buildup in the freezer portion of the mini refrigerator freezer. There was a residential refrigerator with a freezer adjacent to the dining area on the memory care unit. There was a large, dried spill of an unidentified brown substance on the bottom shelf of the refrigerator. Assistant Director of Dietary Services #857 removed several staff lunches and beverages from the refrigerator including several bottled beverages, bagged lunches, a box of pizza, and a frozen dinner. The food and beverage products removed were not labeled with a name or date. Assistant Director of Dietary Services #857 indicated the refrigerator was only for resident foods, and staff were not permitted to store their food in the refrigerator. All findings were verified at time of observations with Assistant Director of Dietary Services #857. Review of the undated facility policy labeled Freezer Storage revealed all food would be stored to prevent freezer burn. The freezer should be maintained at a temperature of zero degrees to negative 10 degrees Fahrenheit. Review of the facility policy labeled Care and Monitoring of Unit Refrigerators, dated August 2017, revealed resident food or beverages brought in from the outside will be labeled with the resident's name, room number, and dated by nursing. The policy did not address cleanliness of unit refrigerators.

Based on record review and staff interview the facility failed to ensure the ombudsman was notified of resident transfers to the hospital as required. This affected five of five residents reviewed for hospitalization , Residents #31, #38, #40, #119 and #270. Facility census was 119. Findings Include: 1. Resident #31 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the census records revealed Resident #31 was discharged to an acute care hospital on 10/19/21 and returned to the facility on [DATE]. Review of both the electronic and paper charts revealed no evidence the office of the State and local ombudsman were notified of Residents #31's discharge to the hospital. 2. Resident #38 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the census records revealed Resident #38 was discharged to an acute care hospital 03/31/22 and returned to the facility on [DATE]. Review of both the electronic and paper charts revealed no evidence the office of the State and local ombudsman were notified of Residents #38's transfer to the hospital. 3. Resident #270 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the census records revealed Resident #270 was discharged to an acute care hospital 12/14/21 and returned to the facility on [DATE]. Review of both the electronic and paper charts revealed no evidence the office of the State and local ombudsman were notified of Residents #270's discharge to the hospital. 4. Resident #119 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the progress note dated 01/10/22 at 1:19 P.M. revealed Resident #119 was discharged to the hospital on 01/09/22. Review of the progress note dated 02/21/22 at 10:58 A.M. revealed Resident #119 was discharged to the hospital on 02/10/22. Review of the progress note dated 03/13/22 at 10:25 A.M. revealed Resident #119 was discharged to the hospital on 03/08/22. Review of the medical chart revealed no evidence the state ombudsman was notified of Resident #119's discharges to the hospital. Interview with the Administrator on 05/04/22 at 10:10 A.M. revealed the facility was not notifying the State or local ombudsman's office of resident discharges to the hospital. The facility notified the ombudsman of facility initiated discharges. Review of a blank copy of the Altenheim Transfer Notice under the subsection notifications revealed a copy of this notice has been sent to the Ohio Department of Health, Legal Services Office, 246 North High Street, Columbus, Ohio and a copy will be sent to the Ohio State Long-Term Care Ombudsman no later than 30 days from the date of the transfer. 5. Record review of Resident #40 revealed she was hospitalized [DATE] due to having a distended abdomen. She returned to the facility on [DATE]. No evidence was found indicating the ombudsman was informed of the transfer. The above finding was confirmed with the Administrator on 05/05/22 at 9:18 A.M. The administrator said the facility did not make ombudsman notification for short-term visits.

Based on interview, record review and policy/procedure review, the facility failed to ensure the responsible party was notified of the development of a pressure ulcer for Resident #100. This affected one of four residents reviewed for pressure ulcers (#9, #100, #103 and #111). The facility census was 99. Findings include: Review of the medical record revealed Resident #100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the profile in the medical record identified a daughter as emergency contact #1 who was also the durable power of attorney. Another daughter was listed as emergency contact #2 and the husband was the third name listed as the A./R guarantor (held accountable for the resident's bill). Review of the skin risk assessment dated [DATE] indicated Resident #100 was at moderate risk for the development of pressure ulcers. A pressure reducing mattress was in place. Review of the comprehensive assessment (MDS 3.0) dated 01/02/21 indicated she was moderately cognitively impaired, and had no pressure sores. She required extensive assistance of two plus staff for activities of daily living. Review of the physician's orders [REDACTED]. Review of the progress notes revealed Resident #100 sustained a significant decline in January 2021. On 01/08/21 at 12:05 P.M. the nutrition note indicated the Resident #100 lost 7.8% in 98 days. Resident #100 was offered additional fluids with medication administration and has been receiving staff assistance with eating. An impaired area to her sacrum was noted with a treatment in place. A plan to add [MEDICATION NAME] (an [MEDICATION NAME]-based powder designed to support the unique nutritional needs of people with chronic wounds (e.g. pressure injury) daily and a supplement three times daily with medication administration. On 01/13/21 at 1:03 P.M. the wound nurse practitioner assessed the resident's coccyx area and ordered a treatment change. It was noted the etiology of the wound was pressure/skin failure. The wound nurse Licensed Practical Nurse (LPN) #200 called emergency contact #1 and gave an update on the condition of Resident #100's coccyx area and the new physician treatment orders. Interview with the director of nursing on 02/02/21 at 2:03 P.M. verified the daughter was not notified of the development of the pressure ulcer until 01/13/21. Review of the notification of change policy and procedure revised in June 2019 indicated under part A)The resident's nurse on duty and/or another member of the interdisciplinary team would inform the resident's provider, the resident and the resident representative immediately whenever the following occurs: A change in a resident's physical, mental or psychosocial status. A need to alter a treatment (i.e., a need to discontinue an existing form of treatment due to adverse consequences or to commence a new form of treatment.) Laboratory results that fall outside of clinical reference ranges. Diagnostic or radiology testing that reflects critical abnormal results and any accident or fall with injury. This deficiency substantiates Complaint Number OH 195.

Based on record review and interview the facility failed to ensure Residents #146 and #165's wound care was provided as ordered by the physician. This finding affected two residents (#146 and #165) of four residents reviewed for wound care. Findings include: 1. Review of Resident #165's medical record revealed the resident was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #165's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment, the resident did not have pressure ulcers. The assessment revealed the resident did have an infection of the foot. Review of Resident #165's physician orders [REDACTED]. Review of Resident #165's physician orders [REDACTED]. Review of Resident #165's physician orders [REDACTED]. Review of Resident #165's physician orders [REDACTED]. Review of Resident #165's physician orders [REDACTED]. care. Review of Resident #165's medication administration records (MARS) and treatment administration records (TARS) from 07/01/19 to 07/10/19 revealed the wound care of the fourth and fifth toes on the right foot was not documented as completed on 07/04/19, the wound care using the Santyl to the left heel was not completed on 07/04/19, the wound care to the left medial foot was not completed on 07/04/19 and the wound care to the left lower extremity using Santyl was not completed on 07/04/19. Interview on 07/25/19 at 4:51 P.M. with Licensed Practical Nurse (LPN) #809 confirmed Resident #165's TAR did not reflect the resident received wound care according to the physician orders. 2. Review of Resident #146's medical record revealed the resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #146's MDS 3.0 assessment dated [DATE] revealed the resident exhibited a memory problem and the resident had a Stage III (extends through the dermis into the fatty subcutaneous tissue) pressure ulcer. Review of Resident #146's physician orders [REDACTED]. Review of Resident #146's MARS and TARS from 07/01/19 to 07/25/19 revealed the resident's left medial heel wound dressing was not completed on 07/06/19, 07/07/19, 07/16/19 and 07/22/19 as ordered. Interview on 07/25/19 at 4:51 P.M. with LPN #809 confirmed Resident #146's TAR did not reflect the resident received wound care according to the physician orders. This deficiency substantiates Complaint Number OH 634.

Based on observation, record review, and interview the facility failed to ensure the kitchen and nursing unit refrigeration were maintained in sanitary conditions and food was stored properly. This had the potential to affect all residents except one, Resident #128 who received nothing by mouth. Findings include: Tour of the kitchen on 04/15/19 from 9:22 A.M. to 9:52 A.M. with Chef Manager (CM) #408 and Diet Technician (DT) #405 revealed in the dry storage room a scoop was observed in a large clear container of dry brown rice. Two unopened loaves of frozen bread were observed on the freezer floor slightly underneath a rack. There was frost and ice buildup on the ceiling near both fans of the freezer. Observation of the Walk-in cooler revealed multiple squished grapes on the floor of the cooler near the back. There was an opened, unlabeled, and undated bag of green onions, red radishes wrapped in saran wrap that was undated and labeled, and a large size clear baggie of herbs that was unlabeled and undated. Interview with CM #408 on 04/15/19 between 9:22 A.M. to 9:52 A.M. verified the above findings. Tour of the nursing units on 04/15/19 from 9:56 A.M. to 10:16 A.M. with Dietary Manager #407 and DT #405 revealed on unit one the microwave behind the nursing station had a brownish spill. There was a large white refrigerator with a freezer. In the freezer was a large, opened container of ice cream that was half gone and a smaller container of ice cream. These containers of ice cream were not labeled or dated. DM #407 stated this refrigerator was for food brought in by visitors for the residents on the unit and should be labeled and dated. Observation of the unit three refrigerator revealed a sticky, clearish substance and multiple spill stains, a blue plastic bag of food that was undated and unlabeled, and two stands of dark colored hair on the bottom shelf of the refrigerator stuck in a sticky substance. Observation of unit four revealed the refrigerator had various dried food spills. The microwave located on the counter above the refrigerator was clean inside but underneath was a moderate amount of a dried, brownish stains and torn pieces of paper towel stuck in it. Observation of the unit five freezer revealed the it was full of frost and contained three, four ounce containers of ice cream that were covered in frost. The microwave located on the counter across from the freezer had dried food splatters. Interview on 04/15/19 between 9:56 A.M. to 10:16 A.M., DM #407 and DT #405 verified the above findings. DM #407 stated housekeeping was responsible for cleaning the nursing unit refrigerators and nursing was responsible for cleaning the microwaves. Review of the facility policy title Food Storage and Leftovers, reviewed 11/19/18 revealed both refrigerated and freezer storage units should be clean and free from moisture and ice buildup. All leftovers that were being stored for future service should be marked with a label that listed the food item and the date prepared. Review of the facility undated procedure for food storage titled How to Store Food Properly revealed best practices for storing food was to label and date all stored food.

Based on observation, record review, and interview the facility failed to ensure the scoop sizes for the pureed food served from the servery for units one and two were correct according to the menu. This had the potential to affect seven residents, Residents #18, #68, #87, #32, #54, #60, and #73 who resided on unit two and received pureed foods. Findings include: Observation on 04/17/19 at 11:53 A.M. of the tray line service in the dementia unit servery for units one and two revealed;ed Dietary Aide (DA) #410 obtaining temperatures of the food on the steam table and Diet Technician (DT) #405 scooping approximately four small cups of pureed macaroni salad using a green handled scoop. Tray line service began a approximately 12:01 P.M. Observation at this time revealed DA #410 serve pureed corned beef sandwich using a green handled scoop and mashed potatoes using a gray handled scoop onto a plate. DA #410 handed the plate to the staff member to place on a tray on the cart for hall trays. DA #410 then grabbed one of the cups of pureed macaroni salads that was previously scooped and handed to the staff who placed it on the tray. Interview on 04/17/19 at approximately 12:16 P.M. with DT #405 verified both the green handled scoops in the pureed corned beef sandwich and pureed macaroni salad were #12. At this time review of the menu spreadsheet with DT #405 revealed the pureed corned beef sandwich should be served using a #6 scoop and the pureed macaroni salad should be served using a #8 scoop. DT #405 stated she was not sure if the pureed corned beef was just the meat or the whole sandwich. DT #405 stated she would get the correct scoop sizes and find out about the pureed corned beef. At approximately 12:20 P.M. DT #405 returned with the correct scoops and verified the pureed corned beef was the whole sandwich. At this time DA #410 indicated she had only served one pureed plate and would make it over using the correct scoops. Review of the facility's undated chart titled Scoop Sizes and Colors revealed the green handled scoop was a #12 which provided a three ounce serving and used for mechanical and pureed meat. The #6 scoop was a white handled scoop and provided a six ounce serving. The #6 scoop was used for casseroles and pureed sandwiches. The #8 scoop was gray handled scoop and provided a four ounce serving. The #8 scoop was used for starch and vegetables. Review of the facility's Resident Summary Report dated 04/17/19 revealed Residents #18, #68, #87, #32, #54, #60, and #73 resided on unit two and received pureed foods.

Based on observation, interview, and record review the facility failed to ensure Resident #103 was served her recommended diet and failed to offer timely assistance with eating. This affected one (Resident #103) of five residents reviewed for nutrition. Findings include: Resident #103 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #103's quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed she required extensive one person assistance with eating. Resident #103's active comprehensive care plan for an alteration in nutrition due to [MEDICAL CONDITION], hypertension, dysphagia, [MEDICAL CONDITION], and weight loss revealed interventions to assist at meals to ensure adequate intake, encourage adequate fluid and oral intake, feed at meals to ensure adequate intake, and honor food preferences. Review of Resident #103's lunch meal ticket for service on 04/17/19 revealed she should receive four fluid ounces of cranberry juice and eight fluid ounces of whole milk with her meal. Observation on 04/17/19 at 12:35 P.M. revealed Resident #103 was served her meal and her head was down. The meal tray did not include four ounces of cranberry juice or eight ounces of whole milk. Observation on 04/17/19 at 12:53 P.M. revealed a staff member came to Resident #103's table but did not wake the resident up to eat. Resident #103 continued to sit with her head down and her food was untouched. Observation on 04/17/19 at 1:00 P.M. revealed a staff member questioned if everyone had ate, but did not come to observe Resident #103's plate that was untouched. Observation on 04/17/19 at 1:04 P.M. revealed a staff member was standing in the dining room, not attending to any resident needs, while Resident #103 continued to have her head down with food untouched. Observation on 04/17/19 at 1:10 P.M. revealed State tested Nursing Assistant (STNA) #406 came to Resident #103's table to record meal intakes. Most resident were no longer in the dining room. STNA #406 woke Resident #103 up and offered to reheat her food, but the resident did not respond. STNA #406 offered the drink that was in front of the resident, and the resident stated not really. STNA #406 retrieved a nutritional mighty shake for the resident, and the resident put her head back down as if she were asleep again. From 12:35 P.M. to 1:10 P.M., no one had assisted the resident with her meal. Interview on 04/17/19 at 1:10 P.M. with STNA #406 confirmed Resident #103 had not touched her food, and confirmed she was not served cranberry juice or whole milk, according to her lunch meal ticket. STNA #406 revealed Resident #103 sometimes fed her self. Interview on 04/18/19 at 10:05 A.M. with Registered Dietician (RD) #501 and Dietary Technician #502 revealed Resident #103's level of feeding assistance had varied from needing a fair amount of assistance and according to the family the resident was able to feed her self now. RD #501 revealed the cranberry juice on the residents meal ticket was a preference. Dietary Technician #501 revealed on 03/13/19 Resident #103's milk was changed from two percent to whole milk because she was losing weight.

Based on observation, interview, and record review the facility failed to follow transmission based precautions for Resident #151 and Resident #54. This affected two (Resident #151 and Resident #54) of six residents observed for transmission based precautions. Findings include: 1. Resident #151 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #151's Skilled Nursing Facility Admit/Readmit Screener admission assessment dated [DATE] revealed she had a right lower quad puncture wound. Resident #151's Skilled Nursing Observation dated 03/08/19 revealed a wound culture of abdomen was obtained. Resident #151's culture wound report dated 03/11/19 revealed she had heavy growth of [MEDICATION NAME] species carbapenem resistance [MEDICATION NAME] (CRE) and heavy growth of pseudomonas aeruginosa. Resident #151's Skilled Nursing Observation dated 03/11/19 revealed the resident was placed on contact precautions for [MEDICATION NAME] CRE bacteria in abdominal wound. Observation on 04/15/19 at 10:35 A.M. revealed Resident #115 had a personal protective equipment kit hanging over her door with a sign that indicated the need to see the nurse before entering the room. Interview on 04/15/19 at 10:35 A.M. with Registered Nurse #403 revealed Resident #115 had bacteria in her wound after a hernia mesh surgery and gown and gloves needed to be worn when in her room. Observation on 04/15/19 at 10:47 A.M. revealed State tested Nursing Assistant (STNA) #402 walking into Resident #151's room without wearing any personal protective equipment. STNA #402 touched Resident #151's personal call pendant to turn it off. STNA #402 did not wash her hands with soap and water before leaving the resident's room. Interview with STNA #402 at this time confirmed she should have worn gown and gloves in Resident #151's room, but did not. Interview on 04/18/19 at 9:50 A.M. with Licensed Practical Nurse (LPN) #401, confirmed Resident #151 had contact precautions in place due to her wound culture showing enterbacter CRE, which was determined to be negative for carbapenemase production on 03/21/19. LPN #401 revealed on 03/25/19 it was discovered Resident #151 wound was colonized for both [MEDICATION NAME]. LPN #401 revealed due to the size of the wound and the amount of organisms in her wound, she remained on contact precautions. LPN #401 confirmed Resident #151 had contact precautions in place on 04/15/19, and when in the resident's room a gown and gloves should be worn. LPN #401 revealed all individuals should wash their hands prior to exiting the room if they had contact with anything. LPN #401 revealed the facility did not have a specific transmission based precautions policy, as the precaution was posted on each resident's door that had precautions in place. 2. Review of Resident #54's record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Nurse's notes and physician's orders [REDACTED]. Review of the change in condition assessment dated [DATE] revealed the hospice Certified Nurse Practitioner (CNP) confirmed a red, moist clustered rash under the left breast and back of Resident #54 was shingles. Observation on 04/15/19 at 5:05 P.M., of Resident #54's room revealed a yellow over the door isolation kit, a contact precaution sign outside the door, and a note on the door that read to see nurse prior to entering the room. Resident #54 was observed sitting in a Broda chair (a large padded wheelchair that can tilt) with a tray table in front of her. Stated tested Nurse Aide (STNA) #409 was in the room without wearing a gown or gloves. Interview on 04/15/19 at approximately 5:06 P.M. with STNA #409 revealed she believed Resident #54 was on isolation precautions for shingles. STNA #409 stated she did not have to wear a gown when delivering trays, only if she was providing resident care. Review of the orange Contact Precaution sign on the door revealed, everyone must put on a gown and gloves at the door. Interview on 04/18/19 at 10:03 A.M. with Licensed Practical Nurse (LPN) #401 revealed the facility did not have a policy for contact precautions, but staff should be following the procedures on the sign. LPN #401 stated staff was supposed to wear a gown and gloves when entering a contact precaution room.

Based on interview and record review, the facility failed to ensure the nurse practioner was notified as ordered when Resident #145's blood sugar was elevated. This affected one of five residents reviewed for unnecessary medications. The facility census was 145. Findings include: Review of the record revealed Resident #145 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the medication administration records for (MONTH) and (MONTH) 2019, where the resident's blood sugar results were recorded, revealed the blood sugar checks exceeded 250 on on 03/07/19 at 9:00 P.M. (275), 03/14/19 at 11:00 A.M. (267), 03/17/19 at 11:00 A.M. (257), 03/18/19 at 4:00 P.M. (285), 03/19/19 at 11:00 A.M. (300), 03/19/19 at 4:00 P.M. (261), 03/26/19 at 4:00 P.M. (276), 03/28/19 at 11:00 A.M. (274) and 03/31/19 at 7:00 A.M. (257). Her blood sugar also exceeded 250 on 04/02/19 at 4:00 P.M. (269), 04/12/19 at 11:00 A.M. (263), 04/12/19 at 4:00 P.M. (268) and 04/17/19 at 11:00 A.M. (271). A phone call to the nurse practioner, Registered Nurse RN #500, on 04/18/19 at 1:45 P.M. revealed she had been called about a few high blood sugars but could not remember specifics of when. She did verify she had not been called about the high blood sugars on 04/12/19 (two elevated levels) or the elevated level on 04/17/19. The assistant director of nursing, Licensed Practical Nurse (LPN) #400, verified on 04/18/19 at 2:00 P.M. that the record did not contain evidence the nurse practioner was notified as ordered.

Based on observation, interview, and record review, the facility failed to ensure Resident #39's skin alteration prevention interventions were in place as ordered. This affected one (Resident #39) of two residents reviewed for skin conditions. Findings include: Resident #39 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #39's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident required extensive two person assistance with bed mobility, transfers, and dressing. Resident #39's physician orders [REDACTED]. bed as tolerated every shift to prevent breakdown, and on 11/08/18 she was ordered ace wraps to bilateral lower extremities in the morning and off at night. Resident #39's active comprehensive care plan revealed she was at risk of impaired skin integrity due to cognitive impairments, decreased mobility, [MEDICAL CONDITION], and fragile skin. Interventions to address this risk were ace wraps as ordered, bilateral soft heel boots when in bed, Dermasavers as ordered, and elevate heels off bed with pillow as tolerated. Observation on 04/15/19 at 2:20 P.M. and on 04/16/19 at 2:02 P.M. of Resident #39 lying in bed revealed her heels were not elevated with a pillow and she did not have Dermasavers, ace wraps, or soft heel boots on. Interview on 04/16/19 at 2:02 P.M. with Licensed Practical Nurse (LPN) #404 confirmed Resident #39's heels were not floated with a pillow, and she did not have Dermasavers to both lower extremities, ace wraps, or soft heel boots on as ordered. LPN #404 revealed the resident digs and digs at her legs. State tested Nursing Assistant (STNA) #405 joined the interview and revealed Resident #39 did not have Dermasavers applied to her upper extremities. Observation on 04/17/19 at 7:30 A.M. of Resident #39's lower legs, revealed her right shin area had reddened areas and her skin was peeling. Interview on 04/17/19 at 7:35 A.M. with STNA #405 revealed there were not Dermasavers or heel boots in Resident #39's room on 04/16/19.

Based on interview and record review, the facility failed to ensure a blood pressure was obtained prior to administering a blood pressure medication as per the physician order. This affected one (Resident #22) of six residents reviewed for unnecessary medications. The facility census was 146. Findings include: Review of the record revealed Resident #22 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] indicated the resident's cognition was moderately impaired. Resident #22 had a physician order [REDACTED]. Review of the Medication Administration Record [REDACTED]. There was no evidence the blood pressure was obtained prior to being given [MEDICATION NAME]. During an interview on 03/22/18 at 1:41 P.M., Registered Nurse #220 confirmed there was no evidence blood pressures were taken prior to the administration of Resident #22's [MEDICATION NAME].

Based on observation, interview, and policy review, the facility failed to ensure infection control measures during medication administration. This affected one (Resident #106) of six residents observed during medication observations. Findings include: During a medication administration observation on 03/20/18 at 8:36 A.M., Registered Nurse (RN) #205 administered medications to Resident #106. The nurse prepared medications and placed the package containing artificial tears eye drops in his pocket. Once inside the resident's room, RN #205 pulled two gloves from his pocket, donned them, and instilled one eye drop in Resident #106's left eye. He touched the tip of the eye drops to the resident's upper eyelid. The nurse changed his gloves and instilled one eye drop in Resident #106's right eye. Again, he touched the tip of the eye drops to the resident's upper eyelid. RN #205 then washed his hands and left the room. On 03/20/18 at 9:00 A.M., RN #205 confirmed he pulled the package containing eye drops and gloves from his pocket. The tip of the eye drops came in contact with Resident #106's eye. He also confirmed he did not wash his hands between the glove change. Review of the facility Ophthalmic (Eye) Medication Administration Policy (September (YEAR)) indicated hands should be washed after removing gloves. The nurse should not touch the tip of the tube or cap (of the eye medication) to eyes, fingers, or any other surfaces.

Based on observation, interview, and record review, the facility failed to ensure a dressing was maintained to a diabetic ulcer. This affected one (Resident #75) of three residents reviewed for pressure ulcers. The facility census was 146. Findings include: Review of the record revealed Resident #75 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident had moderate cognitive impairment and was at risk for development of a pressure ulcer. Review of Resident #75's physician orders [REDACTED]. The physician order [REDACTED]. On 03/21/18 at 10:10 A.M., Licensed Practical Nurse (LPN) #210/Wound Nurse changed the dressings to Resident #75's right great toe and left gluteal fold. There was no dressing observed on Resident #75's right great toe. LPN #210 indicated her interview with the resident revealed the dressing came off in the shower. An interview with Resident #75 indicated her shower was before breakfast. Observation of the wound revealed the wound bed was mainly covered by whitish colored slough (non-viable tissue). LPN #210 measured the wound to be 1.5 centimeters (cm) long by 1.5 cm wide and estimated 80 percent of wound bed was covered by slough. On 03/21/18 at 10:29 A.M., LPN #210 indicated the staff showering Resident #75 should have reported the dressing came off her right great toe so the nurse could have applied a new dressing.

Based on record review and staff interview, the facility failed to accurately code the pre admission screen and resident review status on the Minimum Data Set (MDS) 3.0 assessment for three residents. This affected three of three residents who had a level two serious mental illness and/or intellectual disability, Residents #28, #74 and #81. The facility census was 146. Findings include: 1. Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the pre admission screen and resident review (PASRR) level two evaluation from the state department of mental health dated 05/17/13 revealed Resident #28 had a level two mental illness. Review of section A of the MDS 3.0 assessment dated [DATE] revealed the facility answered no to the question Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability (mental [MEDICAL CONDITION] in federal regulation) or a related condition? 2. Review of the medical record revealed Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the pre admission screen and resident review (PASRR) level two evaluation from the state department of mental health dated 10/07/14 revealed Resident #74 had a level two mental illness. Review of section A of the MDS 3.0 assessment dated [DATE] revealed the facility answered no to the question Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability (mental [MEDICAL CONDITION] in federal regulation) or a related condition? 3. Review of the medical record revealed Resident #81 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the pre admission screen and resident review (PASRR) level two evaluation from the state department of mental health dated 10/25/13 revealed Resident #81 had a level two mental illness. Review of section A of the MDS 3.0 assessment dated [DATE] revealed the facility answered no to the question Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability (mental [MEDICAL CONDITION] in federal regulation) or a related condition? Minimum Data Set (MDS) Nurse #300 verified all off the above findings in an interview on 03/21/18 at 3:45 P.M.

Based on observation and interview, the facility failed to keep the dumpsters covered and failed to keep the area outside of the dumpsters free of debris. This had the potential to affect any resident residing in the facility. The facility census was 157. Findings Include: Observation on 10/04/15 at 9:00 A.M. revealed two of three dumpsters located outside the kitchen were loaded with rubbish and the lids were left open. The area around one dumpster was noted to have three pairs of used gloves laying on the ground by the dumpsters. This was verified with the dietary supervisor on 10/04/15 at 9:10 A.M. Observation of the dumpster area on 10/07/15 at 10:15 A.M. revealed two of three dumpsters were still full of rubbish and the lids were off. Observation revealed a used pair of gloves laying on the ground. This was verified with the dietary supervisor on 10/07/15 at 10:20 A.M.

Based on observation and interview, the facility failed to ensure one cold food item was maintained and served at a temperature of 40 degrees Fahrenheit (F) or below to ensure food safety and minimize bacterial growth during the mid-day meal. Ninety-one of 144 residents could be affected. Findings include: During the service of the mid-day meal on 07/16/14 at 12:00 P.M., food temperatures at the steam table in the main dining room were checked with the assistance of Assistant Director of Dining Services #4 using a stem thermometer. Two metal trays containing pre-served bowls of coleslaw were observed on the top shelf of the steam table. These bowls of coleslaw were not on or immersed in ice. When the temperature of the coleslaw in one of the pre-served bowls was checked at 12:10 P.M., it measured 52 degrees F. Assistant Director of Dining Services #4 was interviewed at the time this cold food temperature was taken, and verified the temperature of the coleslaw. During service of the mid-day meal on 07/16/14 at 12:30 P.M., food temperatures at the steam table in the Unit 2 dining room were checked with the assistance of Assistant Director of Dining Services #4 using a stem thermometer. One metal tray containing pre-served bowls of coleslaw was seen on the top shelf of the steam table. These bowls of cole slaw were not on or immersed in ice. When the temperature of the cole slaw in one of the pre-served bowls was checked at 12:40 P.M., it measured 55 degrees F. On 07/16/14 at 12:41 P.M.,the temperature of the coleslaw was confirmed during interview with Assistant Director of Dining Services #4. According to Assistant Director of Dining Services #4, the dressing used to make the coleslaw salad was a pre-made dressing which contained mayonnaise as an ingredient. Interview with Registered Dietitian #5 on 07/17/14 at 11:52 A.M. revealed 91 residents received coleslaw as part of their mid-day meal on 07/16/14.